Date: Sun 10 Nov 2019
Source: The News [abridged, edited]
<https://www.thenews.com.pk/print/553329-teenage-rabies-victim-awaits-death-at-jpmc-as-vaccine-shortage-persists-across-sindh>

Another young man is awaiting death in an isolation ward of the Jinnah Postgraduate Medical Centre (JPMC) after developing full-blown rabies, as he was bitten by a rabid dog some 3 months ago but was not administered the rabies vaccine, officials said on Saturday [9 Nov 2019].

"18-year-old Z.K., a resident of Jeva Khan Goth in the Nooriabad area of District Jamshoro, has been brought to the casualty ward of the JPMC with full-blown rabies," Dr Seemin Jamali, the hospital's executive director, told The News.

"According to his family members, the teenager was bitten by a stray dog on the leg around 3 months ago. Unfortunately, neither did the family know about vaccination nor did anybody tell them to get the teenager vaccinated, which resulted in the development of the lethal disease."

Sindh Health Department officials said that this is the 22nd case of rabies in the province this year [2019].

M.K., the ill-fated youngster's father, said that after his son was bitten on the leg, he was taken to a local doctor, who had dressed the wound and given him some medicines but had not asked for the teenager to be vaccinated or referred him to a tertiary-care hospital.

Officials said that right now, dog-bite incidents are on the rise in Karachi as well as in other districts of Sindh, with so far more than 200 000 people falling victim to canine attacks.

They added that the population of rabid dogs is also on the rise, and the animals are not only transmitting the disease to their own species but also attacking humans throughout the province.

Dr Seemin said: "These days any person who is bitten by a dog should be given immunoglobulin as well as the full course of the rabies vaccine to prevent the victim from a painful death. Once rabies is developed in a person, there is no cure for their condition."

She deplored the fact that on the one hand incidents of dog-bite are on the rise and on the other, hospitals in the entire province are facing a shortage of the rabies vaccine, due to which the cases are being referred to the JPMC in Karachi.

"Even the Abbasi Shaheed Hospital, which is considered to be a tertiary-care hospital, is referring dog-bite victims to the JPMC after administering one dose of the vaccine," she said.

"As we don't know the status of their vaccination, we have to vaccinate these patients from zero, but this practice is extremely unprofessional, and it can result in the loss of a precious life."

On the other hand, the shortage of rabies vaccine is becoming a serious issue in Pakistan, especially in Sindh, which requires hundreds of thousands of doses to prevent the people from developing rabies encephalitis.

Pakistan used to get most of its rabies vaccine supplies from Indian biotechnology giants and pharmaceutical companies, but after the deterioration of relations between the 2 countries, Pakistan's next-door neighbour reduced those supplies, while production at the NIH is insufficient to meet the local requirements.

In this scenario, experts say there is an urgent need to control the population of stray dogs in the country by hook or by crook. They believe that at a time when there is not enough rabies vaccine available, the authorities should take measures to save people from canine attacks by reducing the dog population by any means.  [Byline: M. Waqar Bhatti]
=====================
[We have received recently several reports from Pakistan, describing human rabies cases; e.g.
<https://www.samaa.tv/news/2019/11/rabies-death-toll-reaches-21-in-sindh/>
(published 7 Nov 2019),
<https://www.thenews.com.pk/print/549907-father-of-six-bitten-by-stray-dog-awaiting-painful-death-at-jpmc>
(published 3 Nov 2019),
<https://www.geo.tv/latest/251263-dog-that-bit-25-people-in-karachi-overnight-found-dead>
(published 15 Oct 2019].

Hopefully, this post will help the professionals involved in getting due attention and required means from the health and municipal authorities for immediate measures undertaken, including timely supply of the required medical preparations.

According to Pakistan's Health Minister, Dr Azra Fazal Pechuho, (on Fri 8 Nov 2019), dog-bite cases were "mishandled" by citizens, as the victims were often brought to hospitals quite late, and the delay caused their deaths (see <https://www.dawn.com/news/1515803>).

WHO's most recent available position paper addressing rabies vaccines and immunoglobulins is available at
<https://apps.who.int/iris/bitstream/handle/10665/259855/WHO-CDS-NTD-NZD-2018.04-eng.pdf?sequence=1>. - ProMED Mod.AS]

[HealthMap/ProMED map available at:
Pakistan: <http://healthmap.org/promed/p/140>]
Date: Fri 8 Nov 2019
Source: Dawn [edited]
<https://www.dawn.com/news/1515576>

Seven cases of the vaccine-derived poliovirus type 2 -- a type of the crippling disease for which vaccinations in Pakistan were stopped in 2014 -- have been detected in the northern areas of the country over the past few months, it has officially been confirmed.

Sources claimed that officials concerned had been reluctant for some time to admit there was any case of the vaccine-derived poliovirus type 2 in the country.

"It is not a wild poliovirus outbreak. It is an outbreak of Sabin-Like Type 2 Derived (SLT2D) [cVDPV - circulating vaccine-derived poliovirus type 2]. Similar outbreaks have been recently reported in Philippines, China, Indonesia, Nigeria, Democratic Republic of Congo, and several other countries in Africa that have completely eradicated the poliovirus," special assistant to the prime minister on health Dr Zafar Mirza told Dawn.

There are 3 serotypes of wild poliovirus: type 1, type 2, and type 3, each with a slightly different capsid protein.

Pakistan has been giving type 1 and type 3 viruses in oral polio vaccines (OPVs), but had stopped administering type 2 vaccine in 2014, and the virus could not be found even in environmental samples since 2016. An environmental sample is declared positive if virus is found in sewage water.

"However, suddenly, cases have been reported from different areas, which means there was some vial left in some laboratory or somewhere else and started spreading due to human error. Just after getting the cases, which cannot be included in the number of wild poliovirus, we sent samples to the lab of Centre for Disease Control and Prevention (CDC), Atlanta, and after getting the confirmation that children were paralysed due to type 2 poliovirus, we have started polio campaigns," Dr Mirza said.

He said the virus had caused 7 cases of paralysis in recent months, mainly in the northern parts of the country. Outbreaks of polio occur where a large number of children were under-immunised, he added.

"The only way to reduce the risks of further transmission is to address gaps in immunisation coverage. The polio programme is working on a comprehensive outbreak response that includes rounds of vaccination in the area to protect every child under the age of 5 years. The programme has also enhanced its acute flaccid paralysis [AFP] surveillance by active search for additional cases, increasing testing of contacts of cases and strengthening environmental surveillance," he said.

He said through the Expanded Programme on Immunisation (EPI) schedule, children in Pakistan receive routine immunisation against 10 vaccine-preventable diseases (childhood tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus, hepatitis B, haemophilus influenza type b, pneumonia, diarrhoea, and measles). Through the service, pregnant women are also vaccinated against tetanus.

The secretary of the Ministry of National Health Services, Dr Allah Bakash Malik, told Dawn that Dr Mirza had directly taken the challenge and was being supported by the entire team in the ministry.  [Byline: Ikram Junaidi]
==================
[In another media report it mentioned that the cases were identified in Islamabad and Diamer district of the Gilgit-Baltistan region (<https://www.samaa.tv/news/2019/11/two-new-polio-cases-reported-in-khyber-pakhtunkhwa-2/>). While Islamabad is a major, capital city that has significant transit of international and national visitors, the Gilgit-Baltistan region, located in a mountainous region of the country with peaks reaching 8000 m [26 247 ft] high, is somewhat distant from major urban centers and shares a southern border with Khyber Pakhtunkhwa. A map showing the districts of Pakistan can be found at  <https://reliefweb.int/sites/reliefweb.int/files/resources/pak215_pakistan_districts_v5_a0_20181203.pdf>.

Information on the genetic profile of the VDPV2 isolates from these 7 cases might help to determine how long these cVDPV2s have been circulating to address the question of approximately when the original OPV2 (oral polio vaccine type 2) was administered. In 2015 there were 2 cases of cVDPV2-associated AFP cases reported in Pakistan, and in 2016 there was one case reported (<http://polioeradication.org/polio-today/polio-now/this-week/circulating-vaccine-derived-poliovirus/>). Possibilities for the origin of the current (2019) cases of cVDPV2 identified in Pakistan include continued use of the trivalent OPV, containing the OPV2 component past the cessation date, continued silent circulation of the cVDPV2 virus from 2015 and/or 2016, or reintroduction of a cVDPV2 from an importation event (a traveler going to Pakistan from an area with known (or unknown) cVDPV2 outbreaks), or reintroduction of an OPV2 virus in a traveler going to Pakistan from a zone where monovalent OPV2 has been used in campaigns to interrupt transmission of the cVDPV2 in an area.

We await further information on the genetic profile(s) of the cVDPV2s involved in the 7 AFP cases mentioned in the above article. - ProMED Mod.MPP]
Date: Thu, 31 Oct 2019 08:53:39 +0100 (MET)

Rahim Yar Khan, Pakistan, Oct 31, 2019 (AFP) - At least 65 people were killed and dozens injured after cooking gas cylinders exploded on a train packed with religious pilgrims in Pakistan on Thursday, authorities said.   Television footage showed flames pouring out of three carriages as people could be heard crying in the incident, in a rural area of central Punjab province.   Some of the passengers -- many of whom were religious pilgrims travelling to a congregation in the eastern city of Lahore -- had been cooking breakfast when two of their gas cylinders exploded, Ali Nawaz, a senior Pakistan Railways official, told AFP.   Many Pakistanis carry food on long train journeys, but gas cylinders are banned, and Nawaz said an inquiry had been ordered.    Dozens of people were crowded onto the tracks staring at the burning carriages, which had been disconnected from the rest of the train, television images showed.

Firefighters later rushed to the scene near Rahim Yar Khan district, extinguishing the blaze. Rescue workers and the army could also be seen, as bodies were carried away covered in white sheets.   "According to information reaching us from the site of the accident, more than 65 people were killed and over 40 injured," provincial health minister Yasmin Rashid told AFP.   The wounded were being rushed to hospitals in the nearby city of Bahawalpur and elsewhere in Rahim Yar Khan district, she said, adding that only 18 of the bodies were identifiable.   "Deeply saddened by the terrible tragedy... My condolences go to the victim's families & prayers for the speedy recovery of the injured," tweeted Prime Minister Imran Khan.    "I have ordered an immediate inquiry to be completed on an urgent basis."

- 'Could have been avoided' -
Khan said the train was the Tezgam, one of Pakistan's oldest and most popular train services, which runs between the southern port city of Karachi to the garrison city of Rawalpindi, next to Islamabad.   But the railways official Nawaz said it had been diverted to facilitate religious pilgrims travelling to Lahore for a congregation there.    The majority of those killed were pilgrims from southern Sindh province, he said.   Nawaz said two of the carriages were economy coaches, while one was business class, and that up to 88 passengers can fit in to each carriage.

Local media reported that some passengers had died when leaping from the still-moving train to escape the blaze. Nawaz said officials were still trying to confirm the details.   "A tragedy that could have been avoided but ever since I can recall while travelling by train no baggage check or restrictions enforced. Tragic," human rights minister Shireen Mazari tweeted.   Train accidents are common in Pakistan, where the railways have seen decades of decline due to corruption, mismanagement and lack of investment.   In July, at least 23 people were killed in the same district when a passenger train coming from the eastern city of Lahore rammed into a goods train that had stopped at a crossing.

Accidents often happen at unmanned crossings, which frequently lack barriers and sometimes signals.   Khan was elected last year on promises to build an Islamic welfare state but an ongoing economic slowdown and austerity measures have hampered efforts to invest in infrastructure and social programmes.   Rural Punjab has witnessed several gruesome accidents over the years.   These included an oil tanker explosion in 2017 when more than 200 people were killed after the truck crashed on a main highway in central Punjab province while carrying fuel from Karachi to Lahore.   It exploded minutes later, sending a fireball through crowds from a nearby village who had gathered to scavenge for the spilled fuel, despite warnings by the driver and police to stay away.
Date: Sat 26 Oct 2019
Source: Pakistan Today [edited]
<https://www.pakistantoday.com.pk/2019/10/26/another-polio-case-surfaces-in-kp/>

The total number of polio cases in the country has touched 77 after an infant was tested positive in Lakki Marwat district of Khyber Pakhtunkhwa (KP). The child had received [zero doses of] essential immunisation, [and he did not] receive any inactivated polio vaccine.

In a press statement issued Saturday [26 Oct 2019], KP EOC Coordinator Abdul Basit said that the virus was spreading rapidly in southern districts of the province, especially in Bannu, which has recorded 32 cases. He said that the only viable solution to the problem is to vaccinate the child in every campaign, as only repeated doses can protect the child from permanent disability and stop the virus circulation. Abdul Basit appealed to the parents not to pay attention to anti-vaccination propaganda. The EOC report cited "refusals by parents" as the top reason for the scale of the virus' resurgence witnessed this year [2019].

KP leads the number of polio cases with 57. Sindh followed with 8 cases, while the number of cases in Balochistan was 7 this year [2019]. Only 5 cases surfaced in Punjab, mostly in its capital Lahore.

One of the reasons is the increased resistance towards vaccination drives and violence against polio workers in the province as compared with the rest of the country.

Prime Minister Imran Khan, last month [September 2019], had expressed serious concern over the recent spike in polio cases in the country and directed federal and provincial government officials to undertake effective awareness and immunisation campaigns to eliminate the disease.
========================
Date: Sat 26 Oct 2019
Source: Urdu Point [edited]
<https://www.urdupoint.com/en/pakistan/polio-case-surfaced-in-lakki-marwat-746608.html>

Another polio case [has] surfaced in Sarae Norang area of district Lakki Marwat said Coordinator Abdul Basit on Saturday [26 Oct 2019]. He said that polio was detected in a 9-month-old baby and the NIH Islamabad confirmed the baby with polio positive.

He said that polio vaccines are a must for children, but unfortunately the parents of the baby did not administer polio vaccines to their child. He said that it is the need of the hour that polio vaccines must be administered to every child to eliminate polio from the area and save their lives. He urged the parents, Ulema-e-Karam and civil society members to play a role in creating awareness among people to administer polio vaccines to their children.  [Byline: Zeeshan Aziz]
========================
[With the addition of this newly confirmed case, the total number of cases reported by Pakistan with dates of onset since 1 Jan 2019 is now 77, and the total number of cases of WPV1 reported globally is now 95. Of note is that 57 of the 77 cases (71.4%) reported by Pakistan this year (2019) were from Khyber Pakhtunkhwa province.

It's a repetitive story of unvaccinated children.

A good map of Pakistan showing districts and provinces can be found at
<https://reliefweb.int/sites/reliefweb.int/files/resources/pak215_pakistan_districts_v5_a0_20181203.pdf>. - ProMED Mod.MPP]

[HealthMap/ProMED-mail map:
Pakistan: <http://healthmap.org/promed/p/140>]
Date: Sun 20 Oct 2019
Source: Pakistan today [edited]
<https://www.pakistantoday.com.pk/2019/10/20/mysterious-throat-virus-claims-nine-lives-in-badin/>

The death toll from a mysterious throat virus has reached 9 children in Seerani and its surrounding localities in Badin district as one more child infected by the virus died, affected people said on [Sun 20 Oct 2019].

A child, R, son of RM, died after contracting the disease. The most affected areas are reported to be Seerani and its surrounding localities. Teams of the health department and other organizations reached Seerani and took blood samples of at least 30 children who were infected by the virus. The blood samples will be sent to Islamabad for the tests.

The people of the area are worried about this new throat viral disease and have demanded authorities to provide immediate health cover to them.
====================
[There is little information to go on other than the throats of children are affected and the case fatality rate is high (10 of at least 30). No other symptoms are provided, nor is the basis for concluding that a virus is involved or what the epidemiological data are (dates, ages, sex of children involved, and local conditions). ProMED-mail would welcome additional information. - ProMED Mod.TY]

[HealthMap/ProMED map available at:
Sindh, Pakistan: <http://healthmap.org/promed/p/707>]
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